May 21-May 26 2015 - The week immediately following surgery

June 17, 2015

Plantarflexion splint and knee walker - got me through the first six days post surgery
I awoke the morning after my surgery on Thursday May 21. I still had the cast/bandage on my right foot with the toes pointed down. My toes were still numb and the nerve block was still clearly in effect from the afternoon before.  I had prepared a bedroom on the main floor of my house in what is normally an office, since my wife and I have our bedroom up a full flight of stairs.  There is also a bathroom on the same floor as my makeshift "bedroom". I had positioned the knee scooter and the crutches next to my bed and sure enough, I had to wake up to pee the previous night, and it was fairly simple to just swing my knee from the bed to the scooter, scoot a couple of short steps to the bathroom, and I could even manage the act of urination while still on the scooter!

The morning of May 21 (the day after surgery) I got out of bed and scooted right over to my power recliner and just settled in.  My toes were quite swollen, so much so that I considered calling the doctor, but as soon as I got my foot up and put a little ice above the bandage I was fine.

About 1500 that afternoon, pretty much exactly 24 hours after my nerve block was administered, it wore off.  The tingling in my toes which had been so annoying disappeared, and I could now feel sensitivity around my stitches and had to make sure to keep my pressure off of that area.  I accomplished this by having the recliner footrest up with a pillow on top, then I just rolled my leg from side to side to keep pressure off the stitches.  The pain was quite manageable - the Vicodin which I had been eating like candy before the surgery was totally unnecessary now and even as I write this, a month after my surgery, I have not felt the need to take a single narcotic pain reliever since the surgery.  A couple of times I have taken two extra strength Tylenol but that is it - no severe pain at all.

So I did not go back to work for that first week and I remained non-weight bearing.  After a couple of days of having my wife bring me my meals, I decided to venture into the kitchen, which required going up two stairs.  Unfortunately, while I had practiced on the crutches before surgery, I did not practice going up and down stairs.  It is harder than it looks.  So the day after my surgery with my wife helping I got off the knee scooter and up on to the crutches - they are basic aluminum underarm crutches that I had gotten from the hospital.  With my wife at the top of the two small stairs I hopped up with one foot to the first step and lost my balance backwards.  I fell back but I knew I could not put any weight on my right leg so I just let myself crash onto my right elbow.  It was a spectacular crash and I severely bruised the elbow but thank God I did not put my foot down and rerupture the Achilles.  Lesson learned. I got back up and with my weight positioned forward managed to hop up the stairs and join my wife in the kitchen for dinner.

The rest of the week was just ice, rest, elevation. I went in for my first follow-up with the orthopedic surgeon on Tuesday May 26, six days after surgery.

May 20, 2015 Surgery - Achilles Tendon Repair

June 15, 2015

My surgery was scheduled for the Reston Surgery Center on May 20, 2015, 10 days after my rupture.  The Reston Surgery Center is a large outpatient facility in the same building as my orthopedic surgeon’s medical group, on the campus of a medical complex which includes Reston Hospital Center, our community hospital. During my second opinion, I had asked the doctor about the safety of having the procedure done in an outpatient facility vs a hospital and he explained that statistically there is no greater risk, and that for an Achilles Tendon Repair (ATR) there is no requirement for any specialized equipment that would require that the surgery be conducted in a hospital.  I was comfortable with the Reston Surgery Center, I had a couple of procedures unrelated to my ATR done there over the years.

Prep was pretty simple, no food after midnight the night before the surgery, no aspirin for a week.  I was scheduled for surgery after lunch.

My wife and I went to the center at lunch time and waited for our 1310 showtime.  At 1415 they told us that the surgeon was running late, and shortly thereafter I went in.  The nurse apologized and said they were late because Dr. Kartelian was working on an unexpectedly complex case, setting an arm, but he would be done soon.

The nurse explained that I would get a nerve block which would numb my leg from the knee down for about 24 hours, and then I would be sedated during the procedure.  They gave me oral Celebrex, an anti-inflammatory, and IV Tylenol prior to surgery, and an IV anti-anxiety drug.  No narcotics.

I should interject here that I hate narcotics and they nauseate me.  The pain had been so bad since the Rupture that I started taking Vicodin several times a day along with Promethazine to prevent nausea.  Now with the nerve block and Tylenol they told me I would not need or get narcotics for the surgery.

An anesthesiologist came in to my bay and stuck a needle behind my right knee and in a few minutes I was completely numb from the knee down.  It was a strange and uncomfortable experience.  My toes tingled, but I could not feel anything from my knee to my toes and I could not move my foot.  I looked at it and “ordered” it to turn left or right and it just did not do anything.  It was like being paralyzed.  Before this had a chance to sink in, they took me in to the operating room, put me on my belly, and knocked me out.

An hour later I came to in the PACU, feeling a little woozy.  There was no pain, I still could not feel my lower leg.  I looked down and there was a big ball where my right foot should be - it was a dressing consisting of a spilnt and plaster with elastic bandages all around and my foot pointed down at a pretty sharp angle. This is referred to as a “plantarflexion splint” and I believe it is the typical post surgery dressing for ATR repair. I was instructed not to bear weight and I was given two pumps for my legs to prevent blood clots (more on those later).  I was wheeled out to my car and hopped in and my wife drive me home.

I was amazingly lucid that evening.  Because our bedroom is up a long staircase we set up a bed on the main floor of my house in a room we use as a small library. I relaxed, kept the leg elevated, and I applied ice frequently to the area right above my dressing.  I was not too uncomfortable and not in pain, but still freaked out about the numbness in my leg as the nerve block was still on.  I had purchased a knee scooter and I used it to scoot to the bathroom and to the bed.  It was a Godsend, I strongly recommend a knee scooter to help you during your non-weight bearing post-op period.

I did not take any narcotics that evening and at bedtime I took a Xanax to relax and fell asleep.

That wasn’t so bad.  My nerve block hadn’t worn off yet.

Opinion and second opinion, pre-surgery opinions

June 15, 2015

The rupture occurred on Sunday May 10, 2015. On May 12 I got in to see my surgeon, Dr. Kartelian.  He described surgical and non-surgical options.  I thanked him and told him that I was going to get a second opinion at George Washington University Hospital, a world-class teaching hospital here in Washington DC.

The following day I got in to see a Professor of orthopedic surgery at the University.  He told me the exact same thing about surgical and non-surgical options that  my "home" orthopedic surgeon, Dr. Kartelian, had told me.  Basically there is a non-surgical option which is not recommended because of the incidence of rerupture, the failure to return me to pre-rupture strength and activity, and the length of recovery.  Surgery had risks from infection and anesthesia but the incidence of each was low and the repair from surgery resulted in very good outcomes and very low chance of rerupture.

After these two consultations I decided to go with the doctor close to my house, Dr. Kartelian.  My surgery was scheduled for the following week, May 2o, 2015.

I am glad I got the second opinion.  While the two opinions were almost exactly the same, the post-op protocols that I discussed with each doctor were polar opposites.  Dr. Kartelian, who ended up performing the surgery, had a very aggressive post-op protocol, moving in to the boot, starting physical therapy, and bearing weight as soon as possible after the surgery.  The Professor at the university was an older man, and he was also a foreign educated physician although he had lived in the US for dozens of years and had fellowships and awards and an excellent reputation.  He told me that his protocol was eight weeks in a long leg cast before I could start therapy - a very conservative approach.  While not the deciding factor, I really liked the idea of an aggressive rehab protocol, and from my reading, this type of therapy was on the cutting edge and patients were having excellent success with it.

I am really glad that I picked the surgeon with the aggressive protocol.  I had some nominal atrophy of my right calf in just the few weeks I was down, I can’t imagine how the leg would look after 8 weeks in a full cast!  Getting in to physical therapy has motivated me to work hard and to get better sooner.  Being able to take the boot off and apply vaso pumps and ice has been a Godsend, although I realize how careful I have to be and how vulnerable I am in those brief intervals out of the boot.

I suggest to anyone who has the opportunity to get a second opinion that you just go ahead and do it.  Ask about the surgery, the anesthesia, pain relief, edema control, clot control, and post-op rehab protocols, as well as anything I forgot to mention.

May 10, 2015 - Right Achilles Tendon Rupture

June 15, 2015

In the previous post I recounted how an innocent stumble resulted in the full-thickness rupture of my already torn right Achilles’ tendon.  It was a beautiful Springtime Sunday at about noon, just outside the ball park (Nationals Park in DC - to see the nationals play the Braves).  I immediately tried to get up but my right leg just didn’t work, I knew immediately that I had ruptured the tendon.  I did not hear a pop or snap, but then again, with a moderate tear already diagnosed, my tendon was probably just hanging on by a thread.  I rolled around, my sons were concerned, and I looked up to see a Good Samaritan, and older lady in a Washington Nationals jersey, hand me a paper wipe to clean my bleeding right knee.  Out of nowhere a lady in scrubs was next to me, telling me she was a nurse and I appeared to be seriously injured.  I told her I had an injured Achilles and I was sure I had ruptured it and she told me to remain still while she called EMS and got me an ambulance.  At the same time, uniformed Nationals Park workers showed up and told me to stay still while they called medical.

My leg hurt bad, and I could not move my right foot up or down. A large hematoma was forming under the skin, and my leg felt as if it was full of fluid.  I thought about my predicament - Washington DC’s Fire and EMS is notoriously incompetent, and hospitals in DC are full of people with gunshot and stab wounds.  There are actual recent cases in the press about DC Fire not responding and leaving people to die. I was not going to risk my care to these clowns.  My two sons, both over 6 feet tall, picked me up and we got over to my car parked just outside the park.  I told the boys to enjoy the game, and I got in my car to head to my neighborhood hospital in Reston, VA, about 2o miles away.  I promised my sons that I would pull over and call 911 if I couldn’t drive.

My advice is that if you rupture your right Achilles, do NOT try to drive.  Post-rupture, your right foot is just a big block at the end of your leg that you cannot flex up or down.  My foot was getting numb and my calf was swollen and filled with fluid.  It was stupid, but I managed to slowly drive out to the Virginia suburbs, about 20 miles.  It hurt like  hell, I called my wife at home and asked her to meet me at the ER with my Vicodin prescription.  I parked outside the ER and drug my bad leg in and stumbled into a wheelchair.  My wife arrived and I chomped down two Vicodin while the intake nurse put a cold pack on my leg.  After a short wait I went in to treatment, the ER doc gave me the Thompson Test and diagnosed the complete rupture.  He started an IV and gave me 1mg of Dilaudid IV and sent me to X-ray.  No bone issues on the X-ray, so I got another mg of Dilaudid (that stuff is fantastic - 8 times stronger than morphine) and he put me in the boot and sent me home.

When I entered the treatment room at the ER the baseball game that I had just left was playing on the TV and it was just starting.  I was in the ER for about 3 hours, so I watched the entire game - our hometown Nationals beat the Braves 5-4!

March to May 2015 - From Moderate Tear to Complete Rupture

June 15, 2015

So, diagnosed with a moderate tear following the MRI in mid-March, 2015, my Physiatrist told me she was no longer my doctor.  She told me to wear the boot for a month and then go and see a surgeon in her practice.  She told me that I was beyond pain management and needed to consider rehab and repair options, including surgery.  She also sent me to physical therapy (PT) during this month.

So from mid-March to mid-April I spent two days a week in PT strengthening the damaged (partial-thickness tear) right Achilles’ tendon (AT)  and wearing the boot most of the time.  I had a pretty pronounced limp from the injury, but still I only wore the boot about half the time.

In mid-April 2015 I had my initial meeting with the orthopedic surgeon, (OS), Dr. Kartelian.  The OS asked how I was, I said about the same, my leg hurt.  He took one look at the MRI and told me that I needed surgery, the question was just when.  I told him that I had a business and pleasure trip to Europe planned from mid-May to  June 2 and we agreed that I would continue PT until the trip, take the trip, and then see him to schedule surgery when I returned on June 2.

So I continued according to plan.  I was set to leave on May 15 to fly to Geneva.  On Sunday, May 10, I arranged to meet my two adult sons at Nationals Park in Washington DC to take in an MLB game.  The Nationals were playing the Atlanta braves for the third game of a three game series that Sunday and the Nats had won the first two games, so we were looking for a sweep.

On Saturday May 9 I went to the gym, rode the exercise bike for 40 minutes and then did all my balance and strengthening exercises on my torn right Achilles’ tendon.  I got up on May 10 and drove in to DC and parked my car at Nationals Park, the Major League Baseball stadium.  I linked up with my two sons who live in DC and we decided to go inside the park and grab a bite of lunch before the game.

It was a beautiful day and I walked with my two sons towards the Center Field gates along Half Street, just a few blocks South of the U.S. Capitol.  Physically I felt good, but I had a slight limp due to my Achilles tear.  It was a lovely warm, clear day without the stifling humidity that comes to DC later in the season.  Walking along, I stumbled just a bit on my left foot - unusual for me because I am usually very sure-footed, but I had on some new shoes and I just stumbled a bit.  I immediately put my right foot down to catch my weight and avoid falling down, and I caught my toe on the top of the curb.  With my right toe on top of the curb, all my body weight came down on my right heel, which did not have the ground to stop it and hyperextended my torn Achilles’ tendon, instantly rupturing it.  I fell straight to the ground, lacerating my right knee.  I was not able to get up, and the pain was intense.  I knew immediately that I had "graduated" from the tear to the rupture club.

Tendinitis and the road to rupture - the pitfalls of cortisone

June 15, 2015

I started having Achilles tendon pain and inflammation around the time I ran the Marine Corps Marathon in 2007.  I was able to manage the intermittent pain and swelling with NSAIDS, especially Motrin. The tendinitis came and went over the next few years, increasing with my level of activity.  I stopped doing several longer runs in favor of 5K’s and 5 milers and I noticed as my training miles increased, so did the frequency and intensity of my Achilles pain.  In addition to NSAIDS I used compression socks, but nothing really gave me very good relief.

In Fall of 2011 I was training for a marathon and the right tendon really flared up, to the point that it was impeding my workouts and I could feel nodules.  I went to my primary medicine physician and he referred me to a physiatrist at a local orthopedic medicine group.  The physiatrist (an MD specializing in rehabilitation and pain management) said that I was stuck in a cycle of inflammation, and I needed to get that inflammation under control to get my pain under control.  She prescribed 800mg Motrin 3 times per day (the max dosage) and the use of Voltaren Gel, a prescription anti-inflammatory.

I continued to train and to use the anti-inflammatories, but my right Achilles tendon in particular presented severe tendinitis.  After a few months of anti-inflammatories, my physiatrist suggested a cortisone injection to get the swelling under control.  She warned me that these injections were associated with Achilles Tendon Rupture (ATR) and told me that I would have to lay off any exercise for a few weeks after the injection.  She also told me that she could not inject directly into the tendon, just around it.  We went ahead with the injection and within a few days my inflammation was gone and I felt fine.  I laid off of running, but I was feeling completely normal post-injection for the fist time in years.

About a month after my first injection, I was out in the yard splitting wood and I tripped over a vine and fell, hyper-extending my right Achilles tendon.  Immediately I felt the swelling and inflammation flare up again, and about a week later I went back to the physiatrist and I asked her for another cortisone injection, which she gave me.  Following the second injection I took a nice layoff over the holidays, and in early 2012 when I resumed running workouts I was doing fine.

Throughout 2012 and 2013 I picked up my mileage, sometimes with sore Achilles tendons and sometimes not.  My right was always more sore than my left, and had the nodules that I could feel about mid-length.  In 2013 I ran the Army Ten Miler here in Washington DC and felt great, then in Spring of 2014 I ran the Rock and Roll DC Half-Marathon and felt very good doing it.  I continued training in 2014, with intermittent Achilles tendinitis plaguing me, and treating it with lots of anti-inflammatories.

In October 2014 I ran the Army Ten Miler in Washington DC.  I had been busy and had not done as much distance work as I should have, but I gutted it out and ran the race with a great time, close to my personal record.  After the race, my Achilles tendonitis returned with a vengeance, particularly in my right Achilles tendon.  In retrospect, running a ten mile race without the proper training base was a good recipe for injury.  I went back to the physiatrist and I explained what I was experiencing and I told her that I wanted another cortisone shot since they had worked for me before.  She again warned me of the association between cortisone shots and ATR rupture, but said that this would only be about my third shot in three years, and she shot me up again in mid-November, 2014.

After my cortisone injection in November 2014 I felt great - the swelling went down and I went back to daily 3 mile training runs.  I was fine for about six weeks, and then in early January, 2015, I had a twinge in my right Achilles after a run.  It got worse, and developed into a serious case of tendinitis.  I went back to the physiatrist and she told me to rest, ice, and use anti-inflammatories.  I stopped running and instead switched to using and exercise bike and and elliptical trainer, which didn’t put as much strain on my Achilles.  Since the last cortisone shot only gave me about 6 weeks of relief she ruled that out as an option for additional treatment.

On Valentine’s Day 2015 I went to the gym at lunch time and did a vigorous workout on the elliptical trainer.  Afterwards, my right Achilles flared up and for the first time seriously impaired my walking - I had suddenly developed a limp due to a sharp pain in my right Achilles.  I continued to limp around, as I had some international travel to do, and my limp and the pain grew worse.  Around the beginning of March 2015 I awoke one morning to find a hematoma under my skin around my right heel.  This, coupled with increasing pain, lead me to go to the ER.  The ER doc examined me and told me that my Thompson test was good - no rupture, but he was concerned about the pain, the nodules, and the bleeding.  He splinted me and sent me to an orthopedic surgeon in the same practice as my physiatrist.  The OS ordered an MRI and it came back, in mid-March 2015, as a small but moderate partial-thickness tear in my right Achilles a couple centimeters above my right heel.

Now that I had my diagnosis, physical therapy and a walking boot were prescribed for me, which I began immediately.

A footnote - in retrospect, I would never have taken the cortisone injections.  All the literature I can now find, plus my doctor’s own warnings to me, list cortisone injections as a leading contributor to rupture, and I had multiple injections in the area of the Achilles which tore and eventually ruptured.  I think part of the problem is that I went to a pain doctor to manage my tendinitis. In retrospect, I should have consulted an orthopedist. The very first thing my orthopedist told me when he examined me post-tear was "NO MORE CORTISONE!"  I think that someone who sews these things together for a living would have advised me against the injections, although in defense of the physiatrist, she did warn me.  Right before she shot me up.

I was on the road from a tear to a complete rupture - which came not long afterwards.

First Post!

June 15, 2015

Hello everyone. I had trouble getting the blog set up but I am here now and anxious to share all the details of my Achilles story. I am a 57 year old white male and I have been athletic my entire life. I live in Northern Virginia, just outside of Washington, DC, and I am a partner in a small consulting firm. I played Football in high school, Rugby in college, and have been doing recreational distance running since college, mostly 10-mile and half-marathon distances with a couple of marathons thrown in. I am 5′10" tall and I have a heavy frame and while active and athletic I have struggled with my weight my whole life, from the high end of normal to the low end of overweight, but I have never stopped being very active both outdoors and in the gym, averaging 15-20 miles of running per week over the last 35 years or so. While I am progressing well now almost 4 weeks post-ATR surgery on my right Achilles tendon, I want to go back in time and give you the whole history of my tendinitis, treatments, Achilles tear and eventually my rupture and repair.